Community Recreation Program Registration Form Date: Youth Name: Birthday: Address: Postal Code: Phone#: Email: Parent/Guardian Name: Phone#: Relationship: Address: CellPhone: Care Card#: Select One: JUNIORS (9-12 YEARS OLD) SENIORS (13-18 YEARS OLD) How did you hear about the Community Recreation Program at Chilliwack Community Services? Select Source Facebook or other social media Newspaper Radio Ad Signage on a CCS Building Website Word of Mouth Referral from Local or Government Agency Other Other Parental/Guardian Consent and Waiver Form I, give permission for my son/daughter/ward: to attend: Dates: Locaton: If any problems occur with my son/daughter/ward during the activity, I understand that they will be sent home early, if needed. Those youth who choose not to follow program rules or instructions of the adults during the activity may not be permitted to attend future events as a result. Experience has shown that in connection with youth activities, there are times when illness or accidents may occur and immediate surgical or medical attention is necessary. I give my permission for the Chilliwack Community Services staff member in charge, or designate, to make arrangements for qualified surgical or medical attention for my son/daughter//ward in the event of an emergency without my prior approval. I understand that I will be notified by the quickest means possible if this authority is exercised. I have read and understood the above information. I acknowledge that the program involves a degree of risk that could result in injury, death, loss or damage to person or property, and I understand that my son/daughter/ward is participating in the above program at his or her own risk. After carefully considering the risk involved and in view of the fact that Chilliwack Community services is a non-profit organization, I hereby release, hold-harmless and waive all claims associated with this program which I may have against Chilliwack Community Services, its employees, officers, directors, agents, volunteers and members. I have read about the nature of the program and hereby give my permission for my son/daughter/ward to attend and participate in it. My signature serves as a release and waiver of claim(s) as I am the parent or legal guardian of the above stated child/youth. Parent/Guardian Name (Print) Relationship Parent/Guardian Signature: Date: Contact Phone#: Address: Alternate Contact & Phone #: Email: Care Card# (for emergencies only): 2020 Code of Conduct – Youth Recreation Program As a participant of the Chilliwack Community Services Youth Recreation Program, I commit to an overarching standard of respect: I will respect my peers and treat them with dignity. I will respect both the staff and volunteers who run program. I will treat them with decency, listen to their directions, and comply with their safety instructions. I will respect my environment by cleaning up after myself, and positively contribute to the space that I occupy, leaving it better than I found it. I will respect my community in both the verbal and nonverbal interactions that I have while in program, or while representing my membership as a Chilliwack Community Services Recreation Program participant. I will use respectful and inclusive language, and refrain from using words or engaging in conversations that are derogatory, exclusive, or intentionally harmful. I will respect myself by representing myself positively, engaging in program in a way that is constructive, and setting and politely communicating boundaries when I feel unsafe or uncomfortable. I have read the information presented in this document carefully, and agree to abide by the terms laid out: 2020 Disciplinary Policy – Youth Recreation Program A three-tiered approach to discipline will be instituted when the Code of Conduct is violated: A youth’s first offense will result in a verbal warning by a staff member to the youth. A youth’s second offense will result in a written warning which will need to be signed by both the youth and a parent or guardian. A youth’s third offense will result in a formal meeting at the Youth Services office with the youth, the involved staff, and the Youth Services Coordinator. The purpose of this meeting will be to work as a team to create a reconciliatory path forward whenever possible. Aggressive or excessively disruptive behaviour, as defined by the staff member, is grounds for an immediate suspension from programs for the rest of the day. The parent or guardian will be informed and the youth will be discharged from program. This situation may result in a formal meeting at the Youth Services office with the youth, the involved staff, and the Youth Services Coordinator. 2020 Concerns and Complaints – Youth Recreation Program Written or verbal complaints can be directed to the Youth Services Coordinator. Nikki Dionne [email protected] 604-702-2903 I have read the information presented in this document carefully, and agree to abide by the terms laid out: Initials of Youth Initials or Parent/Guardian Photo Release Form I authorize Chilliwack Community Services (“CCS”), its employees, and agents to do the following: Photograph, film, or otherwise reproduce my photo or likeness Publish, exhibit, and otherwise use my photo or likeness in any manner that CCS deems appropriate, including publication of my photo or likeness in print form or on the Internet, without payment to me. The following items are what I acknowledge CCS to use my photo or likeness for: Newspaper Social Media Print Media I acknowledge and agree that: I have waved any rights regarding the lawful use of my likeness by CCS as described above; I have waived any right to inspect or approve reproductions of my photo or likeness before theyare used by CCS; CCS cannot control the unauthorized use by other persons of my photo or likeness once it hasbeen published and made public CCS will not be responsible for any unauthorized use by other persons of my published name,photo or likeness after it has been published and made public; All material CCS creates using my photo or likeness will be the sole property of CCS. I, agree and accept these terms on I, do not agree and accept these terms on Signature: Phone#: Signature of Witness: Print name of Witness: Send
